PERSONAL
PROFILE
Sumner Marshall is a Clinical Professor of Urology at the University of California Medical Center in San Francisco. He retired from his Urology Private Practice in 2001 and recently retired from a Urology Clinic at the Berkeley campus of the University after directing it for 13 years. He continues to teach at the Medical School.
Sumner Marshall is a Clinical Professor of Urology at the University of California Medical Center in San Francisco. He retired from his Urology Private Practice in 2001 and recently retired from a Urology Clinic at the Berkeley campus of the University after directing it for 13 years. He continues to teach at the Medical School.
INTRODUCTION
First and foremost, it is critical that
your audience be engaged. For this purpose I use stories of personal
experiences both with my referring medical providers as well with teaching of
the medical students. Each of the conditions discussed in the first section of this document
is introduced by a letter from the referring medical provider outlining the
issues of concern. This is followed by my response, in which I attempt to
impart my thoughts and recommendations in an instructive yet informal
style. Although all of these cases are
based on actual encounters, the names of the people involved have been altered
or omitted to insure their privacy.
The medical provider should present all options to
the patient and to be sensitive to his/her responses. Close observance of the
patient’s verbal and body language is essential. There should be an interactive
discourse between the patients and medical provider, conducted in a relaxed
environment as free from time constraints as possible.
One basic tenet has always guided my
approach to the patient: the cure must never be worse than the
disease. Many diagnostic and
therapeutic measures have attendant risks which may actually be more damaging
than the underlying medical problem itself. Not all abnormalities need active treatment.
Therefore, whatever diagnostic or therapeutic modalities I suggest, I try to
evaluate their risk/benefit ratio in light of the natural course of the
disease. Before embarking on any particular plan, I discuss the options with
the patient (and include family members or partner, if the patient so desires). Occasionally surveillance only is my recommendation
and some patients feel uncomfortable with a non-active approach. As I so often
tell my referring medical providers, one
of the most difficult things to do is to do nothing.
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CONDITIONS DISCUSSED:
1. PSYCHOSOMATIC CONDITION
2. PAINFUL URINATION:
a. No Infection ever found in the urine.
b. Documented UTIs without associated
fevers.
c. Documented UTIs with fever.
d. Recurrent UTIs
e. Drug resistant UTIs
f. UTIs with indwelling catheter
g. Traumatic urethritis vs. NSU
g. Traumatic urethritis vs. NSU
h. Bubble bath urethritis
3. PROBLEMS WITH URINARY CONTROL:
a. Urinary frequency
b. Enuresis
c. Stress incontinence
d. Post-void dribbling
4. PENILE PROBLEMS:
c. Stress incontinence
d. Post-void dribbling
4. PENILE PROBLEMS:
a. Erectile dysfunction
b. Warts
c. Herpes
d. Peyronie’s disease
e. Phimosis in adult
e. Phimosis in adult
5. CIRCUMCISION:
a. Is it necessary?
b. Newborn with and without anesthesia
6. PAINLESS SCROTAL PROBLEMS:
a. Hydrocele
b. Spermatocele
c. Varicocele
d. Undescended testis
e. Undescended vs. hypermobile testis
f. Testis tumor
7. PAINFUL SCROTAL PROBLEMS:
a. Tender testicle without swelling of
scrotal contents.
b. Tender testis with swelling of scrotal
contents.
8. TRAUMA:
a. Kidney
b. Penis
9. IMPAIRED FERTILITY
10. POST-VASECTOMY PREGNANCY
9. IMPAIRED FERTILITY
10. POST-VASECTOMY PREGNANCY
11. ABNORMALITIES OF URINE:
a. Hematuria: Microscopic
b. Hematuria: Gross
b. Hematuria: Gross
c. Proteinuria
12. HEMATOSPERMIA
13. PROSTATIC TREATMENT WITHOUT BIOPSY
14. TERMINALLY ILL PATIENTS:
a. Management
b. Family demands
14. TERMINALLY ILL PATIENTS:
a. Management
b. Family demands
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1. PSYCHOSOMATIC
CONDITION
Dear Sumner,
I am sending you Jocelyn Brent, a 42 year
old woman with complaints of lower abdominal pains for the past 5 years. She
has been a vice president of an advertising firm for about 10 years and is
under constant pressure in her job. While she recognizes that her symptoms are
more severe while at work, she, nonetheless, is certain that there is something
seriously wrong with her kidneys. She has already been evaluated by a
gynecologist, gastroenterologist, endocrinologist, general surgeon as well as
an urologist, and no obvious cause for her symptoms has been found thus far. I
have advised a psychological evaluation but she resents any suggestion that her
problems are based in her head. Quite frankly, I am at my wit’s end in dealing
with her. I would be most grateful if you would see her, and, hopefully, if not
render a cure, at least calm her down.
Dear
Brenda,
As I know you are well aware, Jocelyn is
convinced that she has a real problem.
The bulk of my time with her (about an hour) involved a rather extended
discussion re the anatomy, physiology and psychology of the genitourinary
tract. We went over in some detail the “negative” results from her previous
evaluations, as well as those from my exam. We spoke quite openly about the
fact that the body can definitely be influenced by emotional factors and even
if her symptoms are caused, or exacerbated, by her mental state, the symptoms
themselves are still very real for her. I mentioned to her that although we
(the physicians) did not come up with a diagnosis, in the process of the evaluation, no serious underlying problem was
revealed. (REASSURANCE IS A POWERFUL THERAPEUTIC MODALITY.) I felt that, apropos of your last request in
your referral letter, Jocelyn left my office in a much calmer state than when
she arrived!
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2a. PAINFUL URINATION: NO INFECTION EVER FOUND IN THE URINE
Dear Sumner,
Mattie
is 22 years of age, is sexually active and periodically has painful urination.
She has all the symptoms of a urinary tract infection, but, as per your teaching,
I do not want to give her any antibiotics unless we find an offending organism.
Can you solve her problem?
Dear
Sue,
I can’t thank you enough for your
approach. With no infection having been found in the urine, the problem is
likely on an inflammatory basis which can be caused either from something
ingested or from some environmental factor. All too often, antibiotics are
given empirically, with the result that not only may resistant organisms
develop, but the medication may have undesirable side effects If the symptoms
worsened, the patient should record the date, time of day, what was consumed,
if she was exposed to any environmental factors (such as pollens, heat or cold),
had a new sexual partner and if certain positions increased the pain. If the
problem does not improve significantly in 3 months, an ultrasound study will be
obtained to rule out any obvious anatomical abnormalities which could cause the
problem.
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2b. PAINFUL URINATION: DOCUMENTED UTIS WITHOUT ASSOCIATED FEVERS
Dear Sumner,
Casey will be seeing you in the near
future. Every time she has sex with her boyfriend she gets a urinary tract
infection. He goes to college elsewhere and they are monogamous. They get
together about every 2 months. She had UTIs during her time of toilet training,
but she has had none until she became sexually active. She and her boyfriend
would be most grateful for your help.
Dear
Mary,
UTIs often occur in females around the
time of toilet training and/or with sexual activity. In such cases, a more
detailed urological evaluation could be delayed. I suggested that she void
after sex which avoids urine staying in the bladder for a prolonged time,
thereby decreasing the incidence of organisms implanting in the bladder tissue.
You undoubtedly will be happy to know that there is a normal defense mechanism
in the urethra which discourages the organism from going up into the bladder
and if Casey remains infection-free for a few months, the tissue might regain
its normal defense mechanism. However, it may be necessary to take medication
after sex to prevent recurrent UTIs. Nitrofurantoin is my drug of preference
since it is excreted mainly by the kidneys and is less likely to result in
resistant organisms or secondary vaginal infections. If she feels nauseated
after taking the nitrofurantoin, taking a cookie may help coat her stomach. In
fact, she can share the cookie with her boyfriend! Since Casey was very
concerned about the UTIs and the possibility of underlying anatomical
abnormalities, I am obtaining an ultrasound study. If anything suspicious is
noted, I will follow with further imaging studies. However I am the perpetual
optimist and expect all to be well.
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2c. DOCUMENTED
UTIS WITH FEVER
Dear Sumner,
My patient, Gwenn, who is now 26 years
of age, has had urinary tract infections with associated high fevers since
early childhood. She had an intravenous pyelogram when she was age 3. The
family was told that there was no apparent kidney damage. The records we were
able to obtain from the hospital showed no other imaging studies having been
done. She was treated with a course of sulfa, which cleared the infection.
However, as soon as the medicine was stopped, her infection recurred. Her
doctor said that she may have to stay on medicine for the rest of her life.
What do you think is the best approach for Gwenn?
Dear
Ben,
A high fever with UTI in a female
usually indicates a kidney infection. The infection usually starts in the
urethra and bladder and moves upward. This back-up is called reflux. In this case, I would get an intravenous
pyelogram and, if we can obtain copies of the old films, compare those with the
current ones. I would also obtain a voiding cystourethrogram. We assume there is
reflux when she is infected. If there is reflux when the she is not infected
and/or if there is evidence of kidney damage, some type of anti-reflux
procedure may be advisable. Since Gwenn does not wish to undergo any surgical
intervention and is reluctant to stay on continuous medication, I suggested
post-coital medication. If there is evidence of progressive kidney damage, long
term low dose meds might be considered.
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2d. RECURRENT
URINARY TRACT INFECTIONS:
Dear Sumner,
I would appreciate if you would evaluate a
22 year old woman for me. Since her marriage last April, Sue has had one
bladder infection after another. Her
husband feels like it’s his entire fault (which, indirectly, it probably is!),
and is ready to move into another room! I have treated each infection with 7
day courses of antibiotics, but the infections keep recurring. I realize that
these infections are related to sexual activity, but my dilemma is coming up
with a simple way of “breaking the cycle” of the recurrent infections. Sue (and
her husband!) will be eternally grateful for your help!
Dear
Mary,
You are absolutely correct that most
urinary tract infections (UTIs) in women follow sexual activity, usually
occurring about 24 to 48 hours thereafter.
The organisms, which are normally present in the urethral-vaginal area,
get massaged up into the bladder during intercourse. I suggested to Sue that
she void right after sexual activity, in hopes of “flushing out” the organisms
before they multiply and cause the local tissue reaction with its associated
irritative symptoms. We talked about the fact that the normal, non-inflamed
urethral-vaginal tissue has a “built-in local defense mechanism.” With the recurring infections, this tissue
becomes inflamed, rendering it more susceptible to the offending organisms. I
am hoping that if Sue remains infection free for a prolonged period, there will
be re-establishment of healthy tissue, making it more difficult for these
organisms to colonize. If the simple post-coital flushing technique fails to
achieve this goal, then Sue will take post-coital medication: e.g. one tablet
of nitrofurantoin or trimethoprim sulfa, for a few months (along with
post-coital voiding).
Another case of recurrent UTIs: I asked a 22 year old woman with recurrent UTIs: “Do
these infections occur 24 to 48 hours after sex?” she replied: “Dr. Marshall, that’s hard to say since it’s
unusual that 24 hours goes by without my having sex.”
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2e. URINARY
TRACT INFECTIONS (DRUG-RESISTANT):
Dear Sumner,
I’d like your help. It involves a 26 year old sexually active
woman, Anne Smith, who has had many recurrent urinary tract infections. She has
been treated with various medications and, unfortunately, has had allergic
reactions from both trimethoprim-sulfa and nitrofurantoin. Culture and
sensitivity studies of the current infection reveal an organism which is
sensitive only to injectable antibiotics. I’m reluctant to give these meds
because of their toxicity potential. Anne’s only symptom now is mild discomfort
during urination. I do not know how aggressively I should try to sterilize her
urine. Anne will be making an appointment to see you shortly.
Dear
Glenda,
It was a pleasure seeing your patient,
Anne, although disconcerting that it has been so difficult to clear her
infections. There was nothing unusual in her sexual history. She and her
partner are monogamous. Her partner is circumcised and he has not had any
symptoms suggestive of infections. They engage in vaginal intercourse about 4
times per week. No abnormalities were noted on physical exam. Culture and
sensitivities of a catheterized urine specimen confirmed the findings of an
organism resistant to all of the oral medications tested. Given this situation of the many recurrent
infections, particularly when dealing with the accompanying resistant
organisms, I obtained a renal ultrasound.
Happily no obvious anatomical abnormalities of the urinary tract were
found.
I discussed with Anne the pros and cons
of trying to render her infection free with the use of injectable antibiotics
(as per the results of the sensitivity studies). Since she has not been unduly
distressed by the infectious process, and the infection seems to be limited to
the lower urinary tract (no fevers,
back pain and grossly normal renal ultrasound--as per her request, we did not
do a voiding cystourethrogram), we opted, for the time being, to delay active
treatment of the infection and treat the symptoms of discomfort only.
This plan is particularly expedient when
dealing with a resistant organism and a strong allergic history. I have found
that, with the passage of time, possibly a few weeks or longer, there is often
a shift in the sensitivity pattern, with the emergence of an organism which can
be eradicated with less toxic medications. (Sometimes the “flushing” effect of
a high fluid intake alone can actually clear up the infection without the use
of antibiotics!) Assuming we can,
indeed, clear the current infection, post-coital voiding and appropriate post
coital meds for a few months may help prevent recurrent infections by
reestablishment of a more healthy urethral-vaginal area, providing a less
susceptible environment for the offending organisms. There is, of course, the
possibility that we are still unable to clear the infection without treating
her with injectable medications.
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2f. URINARY
TRACT INFECTIONS WITH INDWELLING CATHETERS:
Dear Sumner:
I would like your opinion about a 45 year
old paraplegic male who has worn an indwelling catheter for the past 12 years
(since his initial injury). He prefers to change his catheter monthly, rather
than to do intermittent catheterization. He complains that his urine has a foul
odor and suspects there is an infection. Should I treat him with antibiotics?
Dear
John:
It is near impossible to sterilize the
urine in the presence of long term catheter drainage. It is important to
distinguish between bacilluria and a clinical
urinary tract infection. (Bacilluria refers to the presence of the organisms in
the urine. A clinical infection is
when these organisms cause manifestations of a disease process) If the only problem is an odor of the urine,
there are medications on the market which can control that problem. If your
patient is not having any undue distress, then antibacterial medication is not
only unnecessary its use may be contraindicated because of the likely emergence
of resistant organisms, which could impede the treatment of subsequent clinical infections. However, since
there can be silent damage to the urinary tract organs and/or the formation of
stones, it might be wise at some point to get some radiological evaluation of
the urinary tract: e.g. renal ultrasound or intravenous pyelogram; if there is evidence of renal damage, a
voiding cystourethrogram should be obtained
as well. Assuming no obvious problem is revealed on these studies,
active urological intervention is not necessary at this time.
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2g. TRAUMATIC URETHRITIS vs
NON-SPECIFIC URETHRITIS
Dear Sumner,
Harry, a 43 year old married man, is sure he has contracted a venereal disease. He told me he woke up to find some sticky, mucous-like material on his pajamas and experiences slight discomfort while urinating. The discharge from his penis has become more marked each time he checks to see if it is still present. On further questioning he admitted to having had a recent sexual contact with an old friend about one week previously. Given the extent of his distress, both he and I would feel much more comfortable if you would advise any further evaluation or therapy.
Dear Scott,
As you know non-specific urethritis (NSU), also referred to as non-gonococcal-urethritis (NGU), is usually caused by chlamydia or mycoplasma organism. However, occasionally the symptoms are caused by an inflammatory process without an offending organism. I sent the first part of his urine for special cultures since chlamydia or mycoplasma organisms do not grow on ordinary culture media. It often takes a week or longer for the results. The symptoms could also be caused by a reaction to a local irritant such as soap, bubble bath or vaginal cream or from local trauma.
As you stated in your letter, Harry has been squeezing his penis fairly often to see if the discharge is still present. In the process, it is possible that these maneuvers themselves are perpetuating the inflammatory process causing the persistent urethral discharge. The urine cultures were negative for mycoplasma and chlamydia organisms. Rechecking Harry’s urethral washings (1st part of the urine) would be advisable after a few weeks would be appropriate. Also it would be wise if Harry used his penis only for urinating for a couple of weeks.
Harry, a 43 year old married man, is sure he has contracted a venereal disease. He told me he woke up to find some sticky, mucous-like material on his pajamas and experiences slight discomfort while urinating. The discharge from his penis has become more marked each time he checks to see if it is still present. On further questioning he admitted to having had a recent sexual contact with an old friend about one week previously. Given the extent of his distress, both he and I would feel much more comfortable if you would advise any further evaluation or therapy.
Dear Scott,
As you know non-specific urethritis (NSU), also referred to as non-gonococcal-urethritis (NGU), is usually caused by chlamydia or mycoplasma organism. However, occasionally the symptoms are caused by an inflammatory process without an offending organism. I sent the first part of his urine for special cultures since chlamydia or mycoplasma organisms do not grow on ordinary culture media. It often takes a week or longer for the results. The symptoms could also be caused by a reaction to a local irritant such as soap, bubble bath or vaginal cream or from local trauma.
As you stated in your letter, Harry has been squeezing his penis fairly often to see if the discharge is still present. In the process, it is possible that these maneuvers themselves are perpetuating the inflammatory process causing the persistent urethral discharge. The urine cultures were negative for mycoplasma and chlamydia organisms. Rechecking Harry’s urethral washings (1st part of the urine) would be advisable after a few weeks would be appropriate. Also it would be wise if Harry used his penis only for urinating for a couple of weeks.
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2h. BUBBLE BATH URETHRITIS
Dear Sumner,
My patient, Gwenn, has been a challenge
for me since the time I first saw her, which was about one year ago. She is a
55 year old single woman who has already consulted two other urologists because
of persistent irritative symptoms of the lower urinary tract. Although no
infection had ever been documented, she had been treated empirically with
various antibiotics, without relief of her symptoms. She underwent both
radiological studies and cystoscopy and even had a psychiatric evaluation, none
of which revealed any obvious abnormalities. She pleads for help. Can you work
any of your magic on her?
Dear
Carol,
I appreciate your confidence in my ability
to come up with a magical cure. I must confess that I felt a bit uncomfortable
as Gwen, during the initial consultation, berated the other physicians that she
had seen. Nevertheless, she was
receptive to my comments that her irritative symptoms could be caused by
something other than infection. She accepted the premise that while urinary
tract infections almost always set off a secondary inflammatory reaction, an
inflammatory reaction can occur without the presence of infection. We went over
some possible causes for her symptoms such as a reaction to perfumed soaps,
vaginal creams or bubble bath products, as well as local inflammation of the
urethral-vaginal area resulting from atrophic urethrovaginitis or vaginal
infection. Gwen volunteered that her symptoms were minimal during the day.
However, every evening, despite relaxing in a nice warm sudsy bubble bath, her
symptoms of irritation flared up. All of
a sudden a wide grin appeared on her face. “Could this pleasurable (albeit
transient) activity of the bubble bath be the source of her problem?” she
asked. “Yes, indeed!” replied I. She
agreed, albeit reluctantly, to give up the bubble baths. She called me last
week and reported that her irritative symptoms had completely cleared and that
she was overjoyed with her new lease on life.
Another Case of bubble bath
urethritis: Twin sons of a physician
received a bottle of bubble bath for Christmas and they took nightly bubble
baths together. After just a few days, one of the boys starting wetting his bed
and complained of pain during urination.
His twin brother had no such problem.
Their physician father became very distraught, even imagining that his
son might end up with a kidney transplant (a good example why physicians should
not treat close family members!) Fortunately his wife, the mother of the children,
suggested in a very calm voice (in no way did she wish to embarrass or seem to
question the accuracy of the diagnostic acumen of her husband) that the bed
wetting and the painful urination might be a result of the bubble bath acting
as a local irritant. The bubble baths were stopped and the boy’s symptoms
cleared completely. However, the
physician father wanted to check out the accuracy of the etiology of the
symptoms. Accordingly, he added some
bubble bath to the tub water of his sons once again. Within twelve hours, the symptoms returned. The
bubble bath was then discarded.
Confession: Since then, my son has had no further such problems
Postscript: I subsequently became aware of many such patients who had experienced these adverse effects from bubble bath/liquid detergents and wrote an article for a medical journal titling it “A Soap Opera.” Shortly after publication of the article, I began receiving samples of bubble bath products from various manufacturers of bubble bath requesting that I try their product on my patient and write an appropriate testimonial as to its safety and, of course, to its pleasurable qualities. Needless to say, neither my wife nor my son would agree to such.
Confession: Since then, my son has had no further such problems
Postscript: I subsequently became aware of many such patients who had experienced these adverse effects from bubble bath/liquid detergents and wrote an article for a medical journal titling it “A Soap Opera.” Shortly after publication of the article, I began receiving samples of bubble bath products from various manufacturers of bubble bath requesting that I try their product on my patient and write an appropriate testimonial as to its safety and, of course, to its pleasurable qualities. Needless to say, neither my wife nor my son would agree to such.
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3a. PROBLEMS OF URINARY CONTROL: URINARY FREQUENCY
Dear Sumner:
Bill Smith will be calling your office for an appointment. He is 75 years of age and is a bit of a hypochondriac. He has been my patient for the past 25 years and claims to be very aware of the way his body “works.” He becomes fixated on particular bodily functions and is currently losing sleep worrying about his current “fixation,” that of urinary frequency. Save for mild problems with his prostate (he claims his stream is “not what it used to be”) he is amazingly good condition. He complains that he has to urinate every hour, day and night. I would be most grateful if you could help Bill (and me!)
Dear Sumner:
Bill Smith will be calling your office for an appointment. He is 75 years of age and is a bit of a hypochondriac. He has been my patient for the past 25 years and claims to be very aware of the way his body “works.” He becomes fixated on particular bodily functions and is currently losing sleep worrying about his current “fixation,” that of urinary frequency. Save for mild problems with his prostate (he claims his stream is “not what it used to be”) he is amazingly good condition. He complains that he has to urinate every hour, day and night. I would be most grateful if you could help Bill (and me!)
Dear
John:
I, too, found no gross abnormalities
on Bill. His prostate was palpably
benign, his urine was free of infection, and his post-void residual was
negligible. We had a rather extensive discussion re the machinations of the
urinary tract. I must admit I had quite a time getting him to accept the simple
concept of intake and output; i.e. what goes in must come out. He enjoys his 2
cups of coffee with each meal and his eight glasses of water during the day.
One very revealing additional bit of information was that, in order to help him
go back to sleep each time he gets up, he drinks a large glass of warm milk. It
was very exciting (and most gratifying) to note Bill’s expression on his face
when he realized that merely modifying his fluid intake could take care of his
problem. (I suggested to the Medical staff that an intake and output chart,
including time, be a part of any evaluation for urinary frequency--with the
advice that different measuring cups be used for what goes in and what comes
out.)
Case of nocturia: During my Urology Residency a man was referred to me from the Medical Clinic because he voided about five times each night. The doctors in the Medical Clinic had run multiple diagnostic studies to rule out any serious medical conditions and none were found. The man told me that he voided at most once during the day. The Medical Clinic doctors had not asked him when he slept. In taking my history I learned that the patient’s main oral consumption was at night since he was a night watchman.
Case of nocturia: During my Urology Residency a man was referred to me from the Medical Clinic because he voided about five times each night. The doctors in the Medical Clinic had run multiple diagnostic studies to rule out any serious medical conditions and none were found. The man told me that he voided at most once during the day. The Medical Clinic doctors had not asked him when he slept. In taking my history I learned that the patient’s main oral consumption was at night since he was a night watchman.
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3b. PROBLEMS OF URINARY CONTROL: BED WETTING (ENURESIS)
Dear Sumner,
I need your advice on how to handle
Beverly, a four year old girl, who wets her bed nightly. I realize that this
situation of itself is not unusual, but her parents are very distraught, and
are not willing to accept the fact that she will likely “outgrow it.” Her
mother has told me--numerous times--how bright and well-adjusted she is and how
she gets along so well with her pre-school classmates. However, as soon as
Beverly walks through the door of my office, she becomes very emotional and
immediately starts crying and clinging to her mother. Her urine is free of infection and no gross
abnormalities are noted on physical exam. When I suggested a trial of
medication, her parents refused this approach.
When I suggested some “counseling” they became very angry. However, they did agree, and in fact, were
most pleased, when I suggested that they have you see her. Are you willing? I
hope so since they’ve already made an appointment.
Dear
Phil,
I appreciated very much your introductory
note on Beverly, particularly with the warning of her seeming emotional
fragility. As my office manager always tells me: “Forewarned is forearmed!” For
that reason, when Beverly first walked into my office (clinging to her mother),
I informed her that I’m a cookie doctor, not a shot doctor. (I always have a supply of chocolate chip
cookies in my office). I chose to examine her in my office, rather than in a
separate examining room. Sitting on her mother’s lap during the exam seemed to
add to her feeling of security. Before embarking on my examination of Beverly,
she and I examined her doll. No abnormalities were found on either Beverly or
her doll.
My approach with Beverly was an attempt to
involve her in solving the problem. Assuming that Beverly really wanted to stop
wetting the bed, I asked her to make a calendar and, if she woke up dry, to
affix a star of her favorite color to that day (for daytime wetting one can
modify the calendar accordingly). If she
wet, she will record possible causes—with the help of her parents. (Phil, I want you to know that some of the
things the kids write down are quite original: e.g. “the dog peed on my leg “or
“my pajamas fell into the toilet.”) In addition, I asked her to postpone voiding
as long as possible, noting the maximum volume of urine she could produce at
any one time. Obviously one of her parents will have to help her collect and
measure the urine. (Whether this actually increases her bladder capacity is not
as important as making her aware of the sensation of bladder fullness, and then
recognize when the time has come to deposit the urine in a proper
receptacle.) I further suggested that
she stop and start the stream during voiding to try to reinforce her awareness
that she can control her voiding pattern. I am well aware that these steps may
not result in totally dry beds, but if we can get any dry nights, this will be a positive start.
I then asked the family to make an
appointment for 3-4 weeks hence in order for me to go over the record with the
child. (Her parents’ eyebrows rose at
the thought of paying for another office visit, but quickly relaxed when they were
told there will be no charge for that subsequent visit.) Phil, it is very gratifying when a child
appears with a big smile, so
pleased that there are some stars on the calendar to show me (besides which,
she also gets a chocolate chip cookie along with my encouraging words). The main point is that she must answer to a
person other than a parent.
Other cases of enuresis:
1. A 5 year old boy who sat quietly in the room sucking his thumb as his mother pointed an accusing finger at him, telling me how “this little brat can never stay dry and always embarrasses us with his constant wetting.” (This is certainly not a very healthy family constellation!)
2. A 6 year old youngster came to office with his mother. Unlike with the case noted above, this mother looked lovingly at her son, smiling at his every word and action. “Dear Johnny,” said she, “tries so hard to stay dry and whenever he does, we give him a reward. Why last week alone he got a new tricycle, a special puzzle and a Mickey Mouse watch.” When I talked to Johnny separately, I asked him how he felt about being dry. He acknowledged that, while it did make him happy to wake up dry, he didn’t want to wake up dry every day, at least not right away. His reason: “Doc, I got it made! Do you see the way I got my Mom twisted around my little finger?”
3. Another mother had a very satisfied look on her face when she brought her son back for a follow-up visit. “Doctor” she said, “you may have all your fancy calendars and chocolate chip cookies, but I discovered a quicker way to stop my son from wetting. I got him an electric blanket and told him that if he wet the bed, he’d electrocute himself. (I personally do not recommend this approach for the treatment of enuresis!)
1. A 5 year old boy who sat quietly in the room sucking his thumb as his mother pointed an accusing finger at him, telling me how “this little brat can never stay dry and always embarrasses us with his constant wetting.” (This is certainly not a very healthy family constellation!)
2. A 6 year old youngster came to office with his mother. Unlike with the case noted above, this mother looked lovingly at her son, smiling at his every word and action. “Dear Johnny,” said she, “tries so hard to stay dry and whenever he does, we give him a reward. Why last week alone he got a new tricycle, a special puzzle and a Mickey Mouse watch.” When I talked to Johnny separately, I asked him how he felt about being dry. He acknowledged that, while it did make him happy to wake up dry, he didn’t want to wake up dry every day, at least not right away. His reason: “Doc, I got it made! Do you see the way I got my Mom twisted around my little finger?”
3. Another mother had a very satisfied look on her face when she brought her son back for a follow-up visit. “Doctor” she said, “you may have all your fancy calendars and chocolate chip cookies, but I discovered a quicker way to stop my son from wetting. I got him an electric blanket and told him that if he wet the bed, he’d electrocute himself. (I personally do not recommend this approach for the treatment of enuresis!)
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3c. PROBLEMS OF URINARY CONTROL: URINARY STRESS INCONTINENCE
Dear Sumner,
I have a delightful 92 year old woman
as my patient who has had progressive bouts of urinary incontinence over the
past 20 or so years. The problem occurs only when she does any physical
activities; there is no leakage when she is in bed. This is particularly
distressing since one of her great pleasures in life had been attending church,
but the embarrassment of wet panties has curtailed this activity. She is very reluctant to undergo any surgical
procedures and has asked me whether there is some “non-invasive” procedure
which will help her. Let me know what
you and she decide is best for her. By the way, Myrtle is one of my favorite
patients, and I am sure she will soon be one of yours as well.
Dear
Kim,
After meeting and talking with Myrtle,
I can certainly understand why she is one of your favorites. Not only is she
delightful, she is also very bright and seemed to grasp the entire subject of
the various approaches to urinary incontinence. For example, she explained to me that urinary stress incontinence is usually secondary to
decreased local support of the urethra and bladder most often occurring in
women after multiple vaginal deliveries. We talked about the options for
restoring the supporting mechanism. As you know, she wanted a non-surgical
approach. We decided to try the “old fashioned” vaginal pesssary. This is particularly useful for high risk
women with medical diseases or for women who just want to avoid any surgical
procedures. I told Myrtle that sometimes local inflammation can occur with the
use of a pessary, and occasionally it can become displaced or even fall out. I
asked her what she would do if the pessary popped out when she was walking down
the aisle in church. Without a moment’s
hesitation she looked at me with a twinkle in her eye and said: “Why, Dr. Marshall, I’d just pick it up off
the floor, and hold it up in the air and ask: Did anyone here loose this?”
Happily, the insertion of the vaginal
pessary did provide satisfactory local support for her cystourethrocele,
resulting in marked improvement of her urinary control (and it stayed in place
both during, as well as after, church services!)
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3d. PROBLEMS OF URINARY CONTROL: POST-VOID DRIBBLING
Dear Sumner,
What can you do with a man who claims he
always has a few drops of urine wetting his underpants when he finishes
urinating? This is the complaint of my 28 year old grad student Roger, who has
never had any documented urinary tract infections or venereal diseases and is
otherwise totally asymptomatic. I have been unable to find any cause for his
problem. I would appreciate your opinion.
Dear
Gretchen,
I hope we have helped Roger solve his
problem. I think that the underlying basis for the leakage is a disturbance of
the coordination of the voluntary and involuntary muscular components of his
urethral sphincter, sometimes referred to as “dyssynergia.” Ordinarily these two components contract
synchronously. Roger, in a conscious effort to stop the urinary flow, would
initiate the voluntary muscle component of the urethral sphincter, perceiving
that he had completed the act of voiding. However, before the involuntary
muscle component contracted, the small amount of urine “trapped” in the
posterior urethra would dribble out spontaneously and soil his pants. (How’s that for an esoteric explanation for a
rather common phenomenon?) By relaxing his perineal muscles at the time of
perceived completion of urination--possibly allowing time for contraction of
the involuntary component--and by applying direct pressure with his finger on
the area of his penoscrotal junction, Roger now ejects those last few drops
from the urethra and thereby avoids the embarrassing wet spots.
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4a. PENILE
PROBLEMS: ERECTILE DYSFUNCTION
Dear Sumner:
I have asked Howard, a 62 year old man, to
call you for an appointment, since I have been unable to provide him with
satisfactory solutions for his problem with maintaining erections. He states he is able to gain a fairly firm
erection, but as soon as he attempts insertion, the penis becomes flaccid. He
has tried oral and intraurethral medications, penile injections as well as a
vacuum pump, all with variable degrees of success. I found no obvious causes
for his difficulties. It’s your turn now! Thanks in advance for your help.
Dear
Craig:
I spent the bulk of my time with Howard
taking a history. I questioned him about his occupation, interpersonal
relationships, the time and situation of onset of his erectile dysfunction and
how he performs sexually under varying circumstances, including
self-stimulation or with a partner-- or partners. (I had a patient consult me because he was
having problems maintaining an erection when with his wife. He had no such
problems when with his mistress.) When I
learned that Howard was able to have firm erections during vacation without the use of medications or devices
I felt confident that he had no physiological disturbance of his erectile
“mechanism.”
My
main approach was one of counseling--and reassurance. I pointed out to him that
while a teenager may be able to attain an erection “at will”, this ability
lessens with age (and Howard realizes that he is no longer a teenager). Our
discussion included the fact that most men over the age of 50, and often
younger men as well, experience intermittent difficulty with erectile function.
But perhaps the most meaningful point of discussion for Howard was his
realization that he often tried to gain an erection even when there was no
sexual stimulation. Almost every time he was unsuccessful. This series of
failures eventually turned into a self-fulfilling prophecy of erectile
dysfunction—at least when he was not on vacation.
If his problem continues, I suggested he utilize variations of the techniques of Masters and Johnson, sometimes referred to as “sensate exercises.” This involves stimulating and subsequently bringing his partner to orgasm without his inserting, the purpose being to avoid any pressure on him to “perform. “ (Usually, during the time of his partner’s being stimulated, he himself becomes aroused--and erect). Hopefully, after a while, Howard will be more relaxed when with his partner and the “problem” will straighten itself out spontaneously. I am optimistic that the self-realization that his reactions are not abnormal will itself be therapeutic. If his problem does not resolve, he agreed to make another appointment for both him and his wife .
Case of positive thinking: A patients told me that on his 85th birthday he wrote in his diary: “Last night I had an erection. I was unable to bend it with both hands.” On his 86th birthday he entered in his diary: “Last night I had an erection. I was able to bend it with both hands. I must be getting stronger.”
If his problem continues, I suggested he utilize variations of the techniques of Masters and Johnson, sometimes referred to as “sensate exercises.” This involves stimulating and subsequently bringing his partner to orgasm without his inserting, the purpose being to avoid any pressure on him to “perform. “ (Usually, during the time of his partner’s being stimulated, he himself becomes aroused--and erect). Hopefully, after a while, Howard will be more relaxed when with his partner and the “problem” will straighten itself out spontaneously. I am optimistic that the self-realization that his reactions are not abnormal will itself be therapeutic. If his problem does not resolve, he agreed to make another appointment for both him and his wife .
Case of positive thinking: A patients told me that on his 85th birthday he wrote in his diary: “Last night I had an erection. I was unable to bend it with both hands.” On his 86th birthday he entered in his diary: “Last night I had an erection. I was able to bend it with both hands. I must be getting stronger.”
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4b. PENILE
PROBLEMS: GENITAL WARTS
Dear Sumner,
Frank is a 43 year old man who will be calling for an appointment to see you shortly. His problem is that of recurrent warts on the shaft of his penis and under his foreskin. He has been treated with various methods including topical lotions, liquid nitrogen as well as fulguration, but the warts keep returning. He is married and claims to have a monogamous relationship. He is uncircumcised. What would you suggest as the next steps, both diagnostically and therapeutically? Assuming you rid Frank of his warts, what can he do to prevent their recurrence?
Frank is a 43 year old man who will be calling for an appointment to see you shortly. His problem is that of recurrent warts on the shaft of his penis and under his foreskin. He has been treated with various methods including topical lotions, liquid nitrogen as well as fulguration, but the warts keep returning. He is married and claims to have a monogamous relationship. He is uncircumcised. What would you suggest as the next steps, both diagnostically and therapeutically? Assuming you rid Frank of his warts, what can he do to prevent their recurrence?
Dear
Percy,
As you probably know, genital/venereal
warts, (also called condylomata acuminata) are caused by the human
papillomavirus. They are very contagious and are spread during oral, genital or
anal sex with an affected partner and usually appear within three months after
contact. The lesions in Frank were quite apparent on both the shaft of his
penis and under his foreskin. I applied
some acetic acid (vinegar), which revealed a few other small areas on his penis
to whiten, suggesting that these areas were also infected (I routinely apply
acetic acid to any male patient when there is a suspicion of genital warts,
since this method may reveal otherwise undetected lesions). However, it is
often difficult to find the lesions in the woman, since they can occur not only
externally, but also deep in the vagina. It is, therefore important that
Frank’s wife be examined by her gynecologist who will likely do a Pap smear and
maybe even a biopsy.
Now for the important questions: how do we
get rid of the warts, and perhaps even more critical, how can we prevent their
recurrence? There is a myriad of caustic agents which can be applied locally.
If any of the lesions appear atypical, I do a biopsy prior to their
destruction. I personally prefer to destroy the lesions with electrocautery,
but cryosurgery or laser therapy is similarly effective.
The only way to prevent a recurrence is to
avoid direct contact with the virus. This means, of course, that the virus must
be completely eradicated in both Frank and his wife (assuming there are no
other partners involved), since the virus is transmitted by skin-to-skin
contact. Unfortunately, there is still a possibility that the virus may remain
in the body even though the external lesions have been eradicated. But, as
Frank says, he and his wife enjoy the skin-to-skin contact and have decided to
use condoms only if either of them becomes suspicious of a recurrence. I should
mention that Frank wishes to keep his foreskin despite the realization that it
might harbor the virus, leading to a greater chance of recurrence.
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4c. PENILE
PROBLEMS: GENITAL HERPES:
Dear Sumner,
How would you manage Peter, a 38 year old
man, with periodic flare-ups of herpes? He is not married, but he tells me that
he has been in a monogamous relationship for the past year. I have checked him
out for the “standard” sexually transmitted diseases (gonorrhea, syphilis,
non-specific urethritis and HIV) all of which were negative. His fiancée,
Melissa, thus far, has shown no signs of herpetic lesions. However, she is
quite concerned that it is only a matter of time before she becomes infected.
First of all, how can we be sure she is currently free of the disease, and what
is the best way available currently to protect her? How can she tell if/when she gets the
disease? Are there tests available to monitor her status? Can Peter take some
medication which will prevent his being infectious?
Dear
Mark:
I had quite a discussion with Peter and
Melissa re the various aspects of genital herpes. I tried to address their many questions.
Herein is a brief summary of our discussion:
First of all, the incidence of genital
herpes is quite high; 25% of women and 20% of men are infected with the virus.
Unfortunately once the genital herpes virus (HSV type 2) gets into the body, it
remains in certain nerve cells for life and may be reactivated at any
time. However, after the first episode,
subsequent outbreaks are almost always of shorter duration, less severe, and
occur less frequently. I commented that it is not known what factors cause the
virus to become active, although flare-ups seem more common during times of
either emotional or physical stress, possibly resulting from an added strain on
the immune system. They were quite aware
that the infection is most commonly spread during the time when there is a
lesion/sore, which can shed viruses, but were taken aback when I mentioned that
Peter could be infectious without any obvious sores being apparent. We
discussed how, with the first episode of infection, there may be associated
flu-like symptoms of fever, muscle aches and malaise and that the initial small
red bumps evolve into blisters and subsequently become painful open sores which
become crusty. These lesions usually heal without leaving a scar. . Since they
engage in oral as well as vaginal sex, I mentioned that HSV type 1, the virus
causing blisters on the lips (commonly referred to as “fever blisters”) can
also be spread to the genital area with oral sex.
Melissa was concerned about her current
status. Although she has not seen any
herpetic lesions on herself, she inquired about tests which could tell if the
virus had gotten into her body, as yet in an undetected state. We will be
obtaining a blood test a blood test which, by checking the antibody titer, will
indicate if Melissa has ever been infected with either HSV 1 and/or 2.
Unfortunately, this test is unable to determine if that person is currently
infectious. Indeed, a person could have genital herpes with a “negative” titer
for HSV. The only sure way of confirming the diagnosis is by culturing out the
virus from a herpetic lesion. Should she
become pregnant while infected with the virus, she asked about the chances of
infecting her fetus. I replied that this would be likely to occur only if she
had an active vaginal lesion at the time of the birth and if so, the delivery
would be done via caesarian section.
The “bottom line” is that Peter and
Melissa must come to a mutual understanding, realizing the potential hazards of
the disease while realizing that they can “live with herpes” as long as they
take reasonable precautions. These precautions include avoiding sexual contact
during any obvious outbreaks, and anytime there is any suspicion or concern,
they would use condoms. I informed them
that although there is no medication currently on the market which has been
proven to prevent transmission of genital herpes, certain medications can
“inactivate” the virus. Indeed, some studies have shown that these medications
can prevent outbreaks for a year or longer. Peter has opted to take
famciclover, one of the antiviral medications.
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4d. PENILE
PROBLEMS: PEYRONNIE’S DISEASE
Dear Sumner,
I have a very upset man with a bent
penis. Jack, who is 48 years old, has
noted over the past couple of months that when he has an erection, there is
some associated discomfort and his penis bends upward at an angle of about 30
degrees but he is still able to have intercourse without difficulty. I am not
sure how much of his discomfort is emotional rather than physical. He is
worried about the possibility of the deformity getting worse, I have told him that I believe he has
Peyronie’s Disease, and I tried to assure him that this was not a
life-threatening situation. He responded that I seemed to be downplaying the
seriousness of his problem. How can I reassure him more effectively? Or perhaps
even more importantly, what measures are available for treating this disease?
Dear
Gwen,
I had the opportunity to talk with both
Jack and his wife about this problem. I
was able to assure them that we are dealing with a benign (non-cancerous)
process that is usually self-limited. However, I did explain that Peyronie’s Disease can produce variable sizes
of plaques from very small to fairly large with accordingly variable degrees of
bend to the penis (during erection). In Jack the plaque has developed on the
upper side of the penis, causing it to bend upward. The etiology for the plaque’s
development is not known although it is likely some type of inflammatory
process. As you pointed out in your letter, Jack is able to engage in
intercourse although he experiences some discomfort with the erection. I explained
to Jack that the inflammatory process generally reaches a plateau after about
one year with no further plaque formation along with resolution of the
discomfort and since a certain percentage of the lesions may actually regress
spontaneously, I generally do not institute active therapy during that first
year.
Therapy is a “mixed bag.” Since the
etiology of the lesion is, thus far, not known, a variety of non-surgical
therapeutic approaches have been tried, ranging from topical and injectable steroidal
and non-steroidal anti-inflammatory preparations to radiation and ultrasound
treatments. The results of these
approaches have been sub-optimal. I have become a bit of a skeptic since, if
there is improvement, it is difficult to know if the improvement is from the
treatment employed or from the natural course of the disease process. If the
penile bend prevents satisfactory intercourse, then surgical intervention is
offered. Since Jack‘s erections are quite rigid, if surgical straightening of
the penis were to be done, it is unlikely that a penile prosthesis would be
necessary.
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4e. PENILE
PROBLEMS: PHIMOSIS IN ADULT
Dear Sumner,
Al is a 62 year old man who has noticed
that his foreskin has been progressively tighter over the past few months and
in the last two weeks he has been unable to retract it at all. Isn’t it unusual that a previously
retractable foreskin should become totally non-retractable? Any idea as to why
this should occur at this time in his life?
He (as well as I) would like your opinion about possible measures that
can be taken to achieve a retractable structure, short of circumcision. If the
foreskin does not loosen despite conservative measures, does this mean he
should be circumcised? Al would like to
keep his foreskin if at all possible. Are there procedures which can achieve
this goal yet still spare the foreskin? Could you take a look at Al (and his
foreskin) and let me know your thoughts and recommendations.
Dear
Miriam,
In the world at large, circumcised men are
in the minority (so obviously not every male needs a circumcision). When a
previously retractable foreskin becomes non-retractable, one should always
think about the possibility of underlying diabetes. And, indeed, Al did have
sugar in his urine and he will be seeing you shortly for a diabetes evaluation.
In the interim, I will see if oral and local anti-inflammatory preparations
(e.g. steroid creams) may decrease the inflammatory process and permit foreskin
retraction once again. Al will try to “stretch” the skin himself by trying to
pull it back at least a few times per day. I mentioned to Al that he always
bring the foreskin back over the head of
the penis, since, with the tight foreskin there is a high possibility that the foreskin could not be brought forward,
referred to as “paraphimosis” which might require emergency intervention to
release it.
Personally I feel very strongly that,
given the possibility of undetected lesions or infections occurring beneath
this structure, it is wise that the entire penile shaft be able to be
inspected. Therefore, if our conservative measures are not successful, once the
diabetes has been brought under good control, then either a dorsal slit (an
incision in the foreskin) or removal of a portion, or all of the foreskin (i.e.
partial or total circumcision) would be recommended. Since Al has become
attached to his foreskin over these many years, if surgery is necessary, then
we will likely do just the dorsal slit.
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5a. CIRCUMCISION:
IS IT NECESSARY?
Dear Sumner,
I have spent an inordinate amount of time
with one of my families, Mary and Bob Rogers, discussing with them whether or
not they should have their soon to be born son circumcised. This is not a
religious issue. Dad is circumcised, as are their other 2 sons, but Mom has
been reading a lot recently about the “brutality” of cutting on a defenseless
newborn, who has no say in the matter. I realize that this is a very
controversial topic, which is fraught with much emotional overtones (as has
definitely been the case in this family!) What is your personal opinion (based
on scientific facts, of course) re. circumcision of the newborn? The family has
requested a consultation with you. I think it would be wise to allot sufficient
time in your schedule to go over the subject with them.
Dear
Myron:
I really appreciated your alerting me to
the possible time which I should allow to talk with the Rogers family about
having their newborn son undergo a circumcision. As you mentioned, they have
literally agonized over this subject for the entire time of Mary’s pregnancy.
The Rogers’ dilemma is made more acute by the fact that all males in that
family are circumcised. They had
obviously read extensively about the pros and cons of circumcision, including
the possible complications of the procedure itself. I tried to act as a
sounding board, while interjecting my own interpretation of the available
material on the subject. While it is a fact that over 80% of males in this
country are circumcised, in the world at large, this figure is probably well
under 5%.
We reviewed the evidence, both pro and con
re circumcision. On the negative side, we considered the risks of the procedure
itself, including reactions to anesthesia (if anesthesia were to be used),
bleeding, infection, secondary scarring, fistula formation, incomplete or
excessive skin removal necessitating surgical revision, and inclusion cyst
formation. On the positive side, circumcision reputedly decreases the chance of
urinary tract infections, HIV infections, penile carcinoma, and carcinoma of
the cervix in women whose partners are circumcised. After spending close to an hour with the
Rogers, I still felt that although they seemed to be leaning toward arranging
for the circumcision, they still seemed a bit ambivalent. I suggested that they
postpone the decision for a bit longer. I also emphasized to them that, if they
opted to defer or not circumcise their son, they should avoid the temptation to
try to retract the foreskin themselves at this time, since it is “normal” that
the foreskin is non-retractable in most boys until they are about 2 years of
age. I remain ever available.
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5B.
CIRCUMCISION (NEWBORN): USE OF ANESTHESIA
Dear Sumner:
I have a family from Berkeley that I’d
like you to see. They wish to have their son circumcised, but they want to be
sure he will not experience any pain during the procedure. They have searched
the internet for information about the risks of local anesthesia in a newborn
as well as the possible physical and psychological trauma which might result if
no anesthetic is used. His father wishes to watch the procedure being done. Will this be OK with you? They will be
calling your office for an appointment.
Dear
Bob:
There is little argument that the use of
some form of local anesthesia in the newborn helps decrease the pain level
during circumcision. I addressed this
issue with the family as well as the possibility, albeit very rare, of an
allergic reaction to the anesthetic.
With their own religious backgrounds, they were already well aware of
the use of wine to sedate the child (the mainstay for religious circumcisions
for centuries!). We also talked about the use of topical anesthetic cream. (To
be effective, it should be applied at least one hour before the procedure is
started.) After much discussion, weighing the pros and cons (including
potential risks) of local anesthesia, all parties involved (parents and
doctor--infant Josh didn’t offer his opinion), decided that local anesthesia
would provide the most effective method off minimizing the discomfort of the
circumcision.
Re their desire to be present during the
procedure, I pointed out very clearly that I wanted to give my full attention
to their child. I.e. I do not want to have to divert any of my attention to
either of them, should they become distressed during the procedure. They both
expressed VERY strong feelings about being in the room, and promised to be
“good.” Using a very tiny needle, I injected less than 1cc. of 0.5% lidocaine
circumferentially in the area just proximal to the foreskin. Josh was quiet and his parents breathed a big
sigh of relief. (As did I!)
Case without anesthesia: Mark, age 4, came to me for
the release of adhesions of the foreskin to the glans (head of the penis). Given his age and level of concern of his
father (although the boy himself was pretty relaxed about the whole thing), I
planned on using a local anesthetic to try to minimize the trauma (mainly for
the parents). When the time came to
proceed, since Mark was not very enthusiastic about having a needle stuck in
his penis, I thought I’d give a quick try to see if I could release the adhesions
without the use of an anesthetic. “OK,
Mark” said I, “This may hurt for just a
few seconds.” A quick maneuver and the
adhesions were released. Mark looked
down, looked up, and with wide-eyed wonderment exclaimed to his father: “Wow, Dad, Dr. Marshall did it with his bare
hands! “
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6a.
PAINLESS SCROTAL PROBLEMS: HYDROCELE
Dear Sumner,
A very tense young man just left my
office, convinced that he has a testicular cancer. Bob is 26 years of age and has been aware of
a scrotal swelling since “as long as he can remember.” He states the mass
causes him no pain, although it seems to be getting progressively tenderer to
touch (his girlfriend expresses her concern every time they are having sex). It
was interesting that Bob commented that the swelling sometimes gets larger
after he exercises, but soon reverts to its previous size. I believe we are
dealing with a hydrocele given the history and the consistency of the mass. And
assuming that the underlying diagnosis is, indeed, a hydrocele, is
interventional therapy indicated? If it gets larger, can’t you just remove the
fluid with a syringe or inject a chemical to destroy the sac?
Dear
Craig,
I had a good talk with Bob and his
girlfriend re his situation. Since the mass did transilluminate, most likely we
are, indeed, dealing with a hydrocele. The cystic nature of the lesion was
confirmed on ultrasound study. I believe that the progressive tenderness of the
testis is likely secondary to the multiple self-examinations along with a bit
of Bob’s “fixation” on this part of his anatomy. Ordinarily unless a hydrocele
is sufficiently large as to cause local distress (either physically or psychologically),
surgical intervention is not necessary. To answer your question about possible
therapy, a hydrocele can be aspirated, but since the lining of the hydrocele
sac secretes the fluid, the sac will likely refill within a few weeks, and,
therefore, if surgery were to be done, it is best to remove the entire sac.
Besides which, sticking a needle into the closed space of the hydrocele runs a
risk of secondary infection.
However, in Bob’s case, these points are
probably moot. Since the swelling has apparently been present since early
childhood and is variable in size, there is very likely a persistent connection
between the scrotal and peritoneal cavities: a patent processus vaginalis.
(Ordinarily the processus vaginalis, which is the channel through which the
testis descends from the abdominal cavity through the inguinal canal into the
scrotum, closes spontaneously prior to birth).
For practical purposes, I would treat this as a congenital hernia and
would advise its repair, along with removal of the hydrocele sac as an encore.
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6b.
PAINLESS SCROTAL PROBLEMS: SPERMATOCELE
(AKA EPIDIDYMAL CYST):
Dear Sumner,
George, a 23 year old man, called me last
week in a panic that he had found an extra testicle in his scrotum. When I examined him, I found a mass above and
separate from his left testicle which seemed to be softer than the testis. I
think that the mass represents a spermatocele although George would like to be
certain that he doesn’t have a tumor. Assuming that it is, indeed, a
spermatocele, can the fluid within it be aspirated and its lining destroyed
with some type of chemical solution, or must the entire mass be removed. If
nothing is done, might it affect his fertility? He will be calling you for an
appointment in the near future.
Dear
Felicia,
George was still quite anxious about the
mass in his scrotum when I saw him in the office today. The fact that the mass
transilluminated and was separate from the testis itself is consistent with the
diagnosis of a spermatocele. A spermatocele is usually thought to arise from
obstruction of an epididymal duct, with the secondary dilatation forming a
cystic structure. Smaller spermatoceles are sometimes referred to as epididymal
cysts. However, we did discuss what procedures might be considered if there was
associated discomfort due to a significant increase in its size, as well as the
potential risks of invasive therapy. In the case of a spermatocele, my own
feeling is that active treatment may cause more problems than surveillance
only. For example, not only might reaccumulation of the fluid occur after
needle aspiration of a spermatocele, but the procedure itself runs a risk of
infection. Even more importantly,
epididymal obstruction can result from both the surgery as well as from the
chemical destruction of its lining (sclerotherapy)--which obviously could
adversely affect his fertility.
At this time, being reasonably certain of
the diagnosis and being assured that there is no life threatening process
present and that it should not interfere with his fertility or sexual function,
George expressed his desire to avoid any invasive procedures. In fact, said he
(with a sheepish grin), he really enjoys the comments he receives about his
“profile” in his tight Speedo bathing suit!
6c. PAINLESS
SCROTAL PROBLEMS: VARICOCELE
Dear
Sumner,
I’d like your opinion on Ralph, a 16 year
old, which came to my office today complaining of a large cluster of wormy-like
structures in his scrotum. From my examination, I believe this is a varicocele.
It was on the left side, and I thought that the left testicle was slightly
smaller than its mate. Does this need
any medical attention? It does not seem
to bother Ralph.
Dear
Marv,
I had a good discussion with Ralph and his
Dad about varicoceles and their possible significance. They were surprised to
learn that about 15% of all men have varicoceles. As is the case with Ralph, most occur on the
left side. This is influenced by hydraulics. The vein from the left testicle
drains into the left renal vein at a right angle, whereas the vein from the
right testicle has a more gradual insertion, draining directly into the vena
cava. This may result in reversed flow
of blood in the left testicular vein stretching and enlarging the tiny veins
above the testicle. This is referred to as a varicocele. The question you pose
is, of course, the critical one: “Does Ralph’s varicocele need any medical
attention?”
Ralph’s varicocele is, indeed, quite
prominent, especially when he is in the standing position. As expected, when he
lay down on the examining table, the varicocele was barely detectable. (This
demonstration was most reassuring to Ralph.)
Ralph’s left testicle is somewhat smaller than its mate. It is certainly
possible that this is secondary to the varicocele, or perhaps just a variation
of his anatomy. I explained that the function of the scrotum is to regulate the
temperature of the testes; added heat from the varicocele can impair sperm
production. (This is one of the reasons for bringing an undescended testicle
into the scrotum at an early age: the other main reason being its increased
potential for malignant changes. Marv,
you may have noticed that the testes of many mammals are usually up in their
abdomen most of the year, descending
into the scrotum during mating season in the spring. Now won’t that little
tid-bit of information make for good conversation at your next cocktail party?)
The main purpose of surgical intervention
is to interrupt or remove the varicose veins in the scrotum in order to detour
the flow of blood into normal veins. Surgery would be advisable only if there
were evidence that the varicocele is causing a problem with Ralph’s fertility
and the most direct way to check his fertility status is to check a semen
analysis. However, since Ralph has no immediate plans for fatherhood, both he
and his Dad preferred to hold off on a sperm count for now. It is difficult to
know whether early surgery will reverse the effect of the varicocele on
spermatogenic activity. In a significant number of men who have undergone
varicocele surgery, there has been improvement of sperm count and motility. It
has not been definitely established whether early interruption of the
varicocele is indicated.
6d.
PAINLESS SCROTAL PROBLEMS: TESTICULAR TUMOR
Dear Sumner,
I need your help with Joe, a
32 year old man, whose wife noticed a firm area on the bottom of his right
testicle about one week ago. The mass appears to be localized and. palpation of
the testis does not elicit pain. I found no other abnormalities on physical
examination. The family’s anxiety level is increased by the fact that one of
Joe’s cousins was recently diagnosed with testicular cancer. (I have known his
family for many years and they have been “surfing the net” for any information
about testicular tumors). What
diagnostic and therapeutic steps should be taken at this time? What about doing
a biopsy of the testicle to see if we are, indeed, dealing with a cancer and if
no cancer were found, the testis could be saved? It does not seem right to remove the testis
on the basis of suspicion alone.
Dear
Harry,
Except for the finding of the distinct
area of firmness at the base of Joe’s right testicle, I found nothing unusual
on exam. For “starters,” I am obtaining a testicular ultrasound study to
ascertain if the firm area that we feel is within the testis itself and if it
is solid or cystic. I feel that any solid mass within the testis itself is highly
suspicious for malignancy. However,
since testicular tumors usually spread via the retroperitoneal lymph nodes, I
will be ordering staging procedures to include abdominal/pelvic and chest CT
scans.
One of the most challenging of your
inquiries was about doing a biopsy on the testis prior to possible
removal. This point is controversial. The standard approach for the surgery is via
an inguinal approach, exposing the spermatic cord and putting some type of
tourniquet around the entire cord prior to delivering the testis into view. If
the mass in question is confirmed to be within the testis itself, given the high probability that there is a
cancer within, along with the chance of causing spread of the tumor by cutting
into it, most urologists (including myself)
would be to proceed with its removal, with analysis of the tissue being
done in the laboratory. However, in the
event we were dealing with a solitary testicle and/or the patient stated that
even though he realized the risk of possible spread if there was a cancer
present, he wanted that testis saved if at all possible, then I would go ahead
with a biopsy, obtain a frozen section, but leave the tourniquet in place until
I got the results of the biopsy and proceed with removal of the testis only if
the pathologist finds a definite cancer therein.
I will be proceeding with a radical
orchiectomy (via an inguinal approach) in the near future. Statistically the
tumor, if present, is most likely to be a seminoma, in which case the cure rate
is very high. Since an elevation of the tumor markers, beta sub-unit human
chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP), could occur from
other testicular tumors such as embryonal cell carcinoma or choriocarcinoma, I
will be getting these studies prior to any surgery. It is interesting that his cousin also had a
testicular carcinoma, suggesting the possibility of a genetic (or maybe even an
infectious or immunological) component with this tumor; studies are currently
going on re these possibilities
I will let you know the findings and
further plans. Hopefully, this will turn out to be a pure seminoma, and all of
the staging studies will reveal no evidence of spread. However, if there were evidence of current
metastases or if there were subsequent recurrence, for most testicular tumors,
adjunctive therapy is quite effective. Needless
to say, we will follow Joe closely over the years to come. I appreciate your permitting me to be
involved in Joe’s care.
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7a. TENDER
TESTICLE WITHOUT INFECTION OR SWELLING OF SCROTAL CONTENTS
Dear Sumner,
George has been seeing me
for the past few months complaining of a very tender right testicle. I don’t
find any swelling of the scrotal contents, and, quite frankly I’m baffled. I
thought that he may have an underlying infection which is not apparent so I
tried him on ciprofloxacin. Unfortunately he is no better. He has an
appointment to see you in 2 weeks. If you can make him all better, I (and he)
would be forever grateful.
Dear
Steve,
I can certainly appreciate your
frustration. I personally prefer to avoid using any antibiotics unless I (or
the lab) can find an infection. A tender testicle without infection or swelling
is usually caused by the muscles going into spasm and irritating the adjacent
nerves. Relaxing the muscles with local heat, such as sitting in a warm (not
hot) tub for 15-20 minutes twice daily, is ideal. If there is no improvement in
2-3 weeks, George could try an anti-inflammatory agent in gradually decreasing
doses such as ibuprophen, which he can get without a prescription: 600 mg (3
tabs) 3 X/D for 3D, 400 mg (2 tabs) 3 X/D for 3D, 200 mg (1 tab) 3 X/D for 3D
then 200 mg (one tab) daily for a month or so. If there is no improvement in
1-2 months, I would obtain a scrotal US to rule out any obvious anatomical
abnormalities.
------------------------------------------------------------------------------------------------------------------
7b. PAINFUL
SCROTAL MASS:
Dear Sumner,
Dear Sumner,
Jose is a 28 year old grad student from
Mexico who gradually developed a painful left testicle about three weeks ago.
He has been able to attend classes, but the painful swollen testicle has
persisted. I worry about having missed a testicular torsion. What is my next
step?
Dear
Peter,
The only situation that causes severe
pain with swelling of the scrotal contents that requires prompt treatment is
twisting (torsion) of the testicle. This usually occurs in a prepubertal male
with hypermobile testes, although it can occur in an adult male as well. The
blood supply to the testicle becomes blocked causing sudden and extreme pain of
the testis. If torsion had occurred, a Doppler Ultrasound would show a
non-functioning testicle secondary to the decreased blood flow. Fortunately most
painful scrotal masses do not require any invasive procedures. Epididymitis is
the most common painful scrota mass. With epidymitis the onset of pain is more
gradual and the pain is less severe. Epididymitis is usually associated with an
infection of the prostate; bacteria and WBCs are found in the urine in most
cases. The swelling could take a long time to subside completely and long term
medication might be necessary. A Doppler Ultrasound study will help clarify the
situation. However, please make an
appointment if either you or Jose wishes to do so.
8a.TRAUMA
(KIDNEY):
Dear Sumner,
Sorry to bother you with what may be an
insignificant problem, but I’m uncertain as to what steps should be taken at
this time. Daniel, a 20 year old man, was hit rather vigorously in his right
flank while playing basketball. Shortly thereafter he noticed some blood in his
urine, but this was just once. Since then the urine has been totally
clear. However, when I saw him in the
office today, I found a few red blood cells in both the first and second
glasses, which, according to your teaching, indicates that the source of the
blood is above the bladder neck, and, given the history of the flank pain,
probably from the kidney. (You see, Sumner, I did stay awake during your
lecture!) Daniel is no longer experiencing any pain. Should I suggest that Daniel hold off on
contact sports for a while? Do I need to get X-rays of his kidneys and, if so,
what kind? What sort of follow-up is advisable?
Dear
Craig,
First of all, my thanks for staying awake
during my lecture and, even more so, for remembering (and using!) the
information of the “3-glass urine.” I agree with you completely that the blood
is most likely of renal origin, and since the urine was grossly red on only one
occasion he probably experienced only a renal contusion rather than any
disruption of the renal collecting system (assuming the bleeding was secondary
to the trauma and not from other causes).
There are a variety of approaches for the
problem of renal trauma. If Daniel’s urine was microscopically free of red
blood cells on follow-up urines, I think it reasonable to obtain just a renal
ultrasound study to rule out any obvious perirenal hematoma or space-occupying
lesions in the urinary tract. However, if there is persistence of the hematuria
and/or Daniel has any return of his back or abdominal pain, I would recommend
obtaining a CT scan (with dye) which will give us a more accurate picture of
the integrity of the renal collecting system (as well as possibly reveal any
problems of other adjacent organs or structures). Happily most of the renal
injuries caused by blunt trauma can be treated conservatively. On the other
hand penetrating injuries have a much greater chance for more serious injuries
usually requiring surgical intervention.
Feel free to contact me if you have any
further questions or concerns.
------------------------------------------------------------------------------------------------------------------
8b. TRAUMA (PENIS):
Dear Sumner,
John is a very embarrassed and frightened 24
year old man who was having a rather vigorous sexual experience with his
girlfriend (she was in the dominant position), when he heard an actual snapping
sound and felt a sharp pain in his penis. He has a diminished urinary stream. His
penis is very tender, swollen and discolored and he is worried that this is the
end of his sex life! How can you find out what is going on here and, more
importantly, what can you do to “make it all better?” Both John and his girlfriend would be
extremely grateful for your help.
Dear Elsie:
This was surely one very distressed young
man. My diagnosis was that of a penile fracture…i.e. disruption of one or both
of the compartments which fill with blood during erection (the corpora
cavernosa). Generally, imaging studies are not necessary since, in such cases,
you can usually feel a distinct firm mass on the penis, which represents the
hematoma at the site of disruption. However, it is important to be certain
there is no associated injury of the urethra.
Since John’s urinary stream was diminished, I obtained a urethrogram.
His channel appeared intact.
Penile fracture is obviously not a very
common occurrence and some physicians treat this problem conservatively, hoping
for spontaneous healing to take place. However, because of the high incidence
of complications with that approach, such as penile curvature and erectile
dysfunction, early surgical intervention may be preferable. Accordingly, after
a rather detailed discussion with John and his girlfriend weighing the pros and
cons of surgery, we did proceed with the repair. The surgery went smoothly and I am optimistic
that John and his girlfriend will have a happy future together (though perhaps
a bit less vigorous than in the past).
-------------------------------------------------------------------------------------------------------------------
9. IMPAIRED
FERTILITY:
Dear Sumner,
Dear Sumner,
I don’t know if the Urology
Clinic is an appropriate venue for discussing the difficulties of Roger’s
fertility status. But since you have an empty slot in your schedule, I’ll ask
your thoughts on the matter.
Dear
Wesley,
I always welcome having the opportunity
to interact with you and your patients. To address the current problem, certain
information should be obtained. For example, how long has the couple been
trying to achieve a pregnancy, has his wife ever been pregnant and are her
menstrual cycles regular? Is either he or his wife on any medications? What
evaluations has either of them already undergone for impaired fertility? Has either had a history of local trauma or
known exposure to radiation or chemicals? Has Roger ever caused a pregnancy
with another woman? Since heat can
impair sperm production, knowledge about duration and temperature of baths or
showers as well as type of underwear he uses may be of significance. Also diet,
smoking, or local prolonged pressure on the scrotum, such as bicycle riding may
be affecting his fertility status.
More active and concentrated sperm are generally in the first part of the ejaculate. Withdrawing after the first spurt of ejaculate prevents the remainder of the ejaculate diluting the first portion. If successful fertilization does not occur with this method, consultation with an infertility specialist may be indicated.
More active and concentrated sperm are generally in the first part of the ejaculate. Withdrawing after the first spurt of ejaculate prevents the remainder of the ejaculate diluting the first portion. If successful fertilization does not occur with this method, consultation with an infertility specialist may be indicated.
----------------------------------------------------------------------------------------------------
10. POST-VASECTOMY
PREGNANCY:
Dear Sumner,
John is a 43 year old patient of mine who
had a vasectomy about 9 months ago (not by you). He had his semen checked at
about 4 months after the procedure, and no sperm was found. Contraception was
then discontinued. It came as quite a surprise to John and his wife when she
missed her period last month, particularly when a pregnancy test done a few
days ago was positive. I immediately
ordered another semen check, with no sperm being found once again. This couple has
been married for 25 years and has 3 children, ranging in ages from 10 to 18.
They are currently trying to decide whether to have an abortion. Needless to
say, this pregnancy has caused considerable strain in their marriage. His wife
categorically denies any extramarital activity. They have always seemed like an
exemplary couple and have done a wonderful job raising their kids. I would be very distressed if this marriage
broke up because of this pregnancy. I would appreciate if you would see John
and try to help sort things out.
Dear
Mel,
Post
vasectomy pregnancies are very rare and usually occur within the first few
weeks of vasectomy because the couple has incorrectly assumed that there is no
need for contraception once the vasectomy has taken place. However, there may
still be residual sperm present within the ductal system at that time. In 1972, I reported on a more uncommon
phenomenon: the transient reappearance of sperm after vasectomy (JAMA:
219:1753, 1972). I had a good talk with
both John and his wife re this study. They both seemed VERY relieved after our
visit together and decided not to interrupt the pregnancy.
Mel, I feel that it is important that the
involved physicians be aware of the possible transient reappearance of sperm
after vasectomy and convey this information to the marital partners. I think
you will agree with me that it is better to err on the side of incorrect
paternity and let the couple work out the situation themselves than to destroy
a marriage by denying the possibility of the husband’s transient fertility.
---------------------------------------------------------------------------------------------------------------------
11a.
ABNORMALITIES OF THE URINE: HEMATURIA (MICROSCOPIC):
Dear Sumner,
As part of my routine procedures as a
primary care physician, I did a urinalysis on Susan, who is a 28 year old
female. The laboratory reported 12-14 RBCs /HPF. A repeat exam one week later
showed similar findings. Susan has never seen reddish discoloration of the
urine. What workup would you propose?
Dear
Miriam,
The presence of an underlying
malignancy is very rare with microscopic as opposed to gross hematuria. The
basis for microscopic hematuria is usually inflammatory/infectious process or a
stone. I would suggest that the urine be examined for both infection as well as
tumor cells. The number of RBC/HPF in the urine is dependent on the
concentration of the urine, reported as specific gravity. A dilute urine (low
specific gravity) would have accordingly fewer RBCs/HPF. A 2-glass urine can usually
determine whether the source of the blood is limited to the urethra or is from
higher up (bladder, ureters or kidneys). Given the high probability of a benign
cause for the microscopic hematuria, an ultrasound study could be the initial
imaging procedure. If none of the studies revealed anything suspicious, the
situation could be reevaluated in 6 months and at increasing intervals
thereafter.
---------------------------------------------------------------------------------------------------------------------
11b. ABNORMALITIES
OF THE URINE: HEMATURIA (GROSS):
Dear Sumner,
How would you manage a 62 year old man
with red urine? Harry, who has been my patient for 22 years, told me during his
yearly routine checkup that for the past 6 months or so he has noted a reddish
discoloration of his urine. Since this
was intermittent with no associated discomfort, he figured that there was
nothing seriously wrong and saw no need to call me earlier. I didn’t want to
alarm him, but, quite frankly, I am, indeed, worried about a possible serious
problem. (I seem to remember from my medical school days that with gross blood
in the urine a tumor somewhere within the urinary tract must be ruled out. Am I
correct in this assumption? I suggested he call your office for an appointment
for the very near future.
Dear
Ben,
First of all, thanks for encouraging Harry
to see me so promptly. As you mentioned in your letter, with the history of
gross hematuria there is a high possibility that a tumor may be present in the
urinary tract. It is, therefore, important to visualize the entire urinary
tract.
The urine cytology revealed no abnormal
cells. However, red blood cells (microscopic) were noted in both the 1st
and 2nd glass urines, suggesting their source to be proximal to the
bladder neck, i.e. from the bladder, ureters or kidneys. A CT scan revealed no
obvious tumors or enlarged lymph nodes. On cystoscopy I found a sessile lesion
which had the gross appearance of a low grade tumor and, indeed, on
histological examination that diagnosis was confirmed. A negative cytology does not rule out the
presence of a tumor. If a tumor is present, it is likely low grade and probably
not invading the deeper layers of the bladder wall.
Consideration
could be given to endoscopic and cytological examination of the ureters and
renal pelvises. I will be looking in Harry’s bladder at three month intervals
for one year and then at increasing intervals thereafter. Should there be
multiple recurrences, consideration would be given to the use of intravesical
therapy, such as chemotherapeutic or an immune boosting agent. Hopefully, the
use of such will not be necessary. Generally in cases of superficial tumors of
the bladder, the overall prognosis is quite good.
---------------------------------------------------------------------------------------------------------------------
11c.
ABNORMALITIES OF THE URINE: PROTEINURIA
Dear Sumner,
Protein
in the urine was noted on my 22 year old African American patient on two
separate occasions. What other exams would you advise?
Dear
Jeff,
Although protein in the urine may
indicate underlying kidney disease, fortunately this is not generally the case.
Proteinuria may also be caused by strenuous exercise, prolonged exposure to
heat or cold or emotional stress. Of critical importance is whether the urinary
protein is temporary or permanent. As with any substance in the urine, the
amount of protein in the urine is dependent on the concentration of the urine
(specific gravity). A 24 hour measurement along with a serum creatinine should help
clarify the situation.
---------------------------------------------------------------------------------------------------------------------
12. HEMATOSPERMIA:
Dear Sumner,
Robert, who is a 44 year old man, will
be seeing you in the near future. He
recently discovered blood on the sheets after having had intercourse with his
wife. She was not having her period at the time. He did not see any blood in
his urine, and there was no associated discomfort with either urination or
ejaculation. Needless to say, he has since been VERY upset, and is convinced
that there is something seriously wrong.
He denies any new sex contacts, although he is now wondering if this is
from some pre-marital “exposure.” I
tried to reassure him that the underlying condition is most likely not serious,
but I think he needs your special touch.
I look forward to hearing your words of wisdom.
Dear
Martha,
I can certainly understand Robert’s
distress. The presence of blood in the ejaculate is very frightening to a man. He verbalized to me that he was afraid he had
a malignancy, a venereal disease, or that this might portend the loss of his
ability to have erections! He seemed a
bit more relaxed when I explained that blood in the ejaculate (aka
hematospermia) is almost always benign in nature caused by an underlying
inflammatory process. The bloody
ejaculates are usually of brief duration, although in some cases they may
persist for years. A urine specimen sent for cytological examination, as
expected, showed no malignant cells. I told him that if the bloody ejaculates
did persist, I would get x-rays of the area and possibly look up into his
urethra and bladder. When he asked what he should do if all of the studies
showed no serious underlying problem and yet the bleeding recurred. I advised
him to have sex in the dark.
-------------------------------------------------------------------------------------------------------------------
13. PROSTATIC CANCER TREATMENT (WITHOUT BIOPSY):
Dear Sumner:
Mr. Y., an 86 year old man, came to my
office last week complaining of progressive slowing of his urinary stream along
with rather severe lower back pains. The back pains lessened with the use of
Tylenol, local heat and bed rest. He is a bit “fragile,” having had a heart
attack about 3 years previously and is generally quite weak. He is currently on
prophylactic low dose aspirin. On rectal
examination I found his prostate to be hard and bumpy. I obtained a PSA level, which the lab
reported as 32 (normal level for that lab is <4). I think he’s probably got
prostate carcinoma. Where should we go
from here? Do we need a tissue diagnosis prior to starting hormonal therapy?
Dear
Bob:
I certainly agree with you about the high
probability of your patient having prostate cancer. The question arises as to the best way of
handling the current situation. I had a
long discussion with both Mr. Y and his family about the “statistics” of
prostatic cancer with increasing age: i.e.
after the age of 70, there is approximately a 70% chance of there being
a focus of cancer in the prostate, over the age of 80, an 80% incidence, and
after 90, almost all men will have a focus of cancer in the prostate. The
message is: if you live long enough, you
will die with, but not from, prostate cancer. (Of course, in this case, he could, indeed,
die from metastatic disease.).
Re the question you brought up about the
necessity of obtaining a tissue diagnosis prior to initiating treatment, under
the best of circumstances, prostatic biopsies run the risk, albeit very low, of
possible complications such as bleeding or infection, not to mention the
discomfort. And taking into account your patient’s age, his past medical
history, the fact that he is on prophylactic aspirin, and the clinical picture
of probable prostatic cancer (PSA of 32 with an underlying firm and irregular
prostate), I would opt for starting him on anti-androgen therapy without having
a tissue diagnosis.
-------------------------------------------------------------------------------------------------------------------
14a. TERMINALLY
ILL PATIENT: MANAGEMENT
Dear Sumner:
I would like you to see Barry, a 68 year
old patient of mine who was diagnosed with renal cancer about 5 years ago. He
underwent a radical nephrectomy shortly after the lesion was discovered. He has
had no recent weight loss and currently has no symptoms suggestive of recurrent
tumor. However, a routine chest X-ray
done a few days ago revealed obvious metastatic lesions. Blood chemistries are
consistent with spread of the tumor into the liver. These came as quite a shock
to both him and his family, since they had been reassured by his previous
urologist that the tumor had been completely removed. Needless to say, some
active steps should be taken to handle this very distressing situation. Although Barry, himself, is currently in no
dire distress, given the radiological and serological findings, we are likely
dealing with a non-curable process that will likely manifest itself clinically
in the very near future. I and the
family will be most grateful for your input.
Dear
Bill:
I had a very frank discussion with Barry
and his family about the various aspects of kidney tumors. It was interesting
to note Barry’s attitude shift from one of anger and total dismay to one of
relative calm as he gradually came to grips with his own disease process. (Of
course, it would have been a better situation if Barry as well as his family
would have already anticipated the possible happenstance of metastatic/terminal
disease before this state actually occurred, but unfortunately, this was not
the case here.) Barry asked some very thoughtful and practical questions about
possible scenarios involving metastatic disease. We spoke quite openly about
the potential conflicts involving the issues of quality versus quantity of life
and the fact that medical technology today has awesome capabilities of
prolonging life. Barry expressed his preferences regarding the future
management of his care, stating quite emphatically that he wanted neither to
have his life prolonged by artificial means, nor to suffer with severe pain. I
think it was also very helpful for Barry to have his family in on the
discussion as he came to grips with his current condition. (This can really
help avoid future feelings of guilt if family members feel that insufficient
steps are being taken to prolong the patient’s life.) Barry and his family
agreed that as his physical condition deteriorated, Hospice care would be
initiated.
---------------------------------------------------------------------------------------------------------------------
14B. TERMINALLY
ILL PATIENT: FAMILY DEMANDS
Dear Sumner:
I am faced with a very difficult
situation. It involves a 79 year old man who was diagnosed with bladder cancer
about 4 years ago. He has since had a stroke, which has left him with left sided
weakness as well as aphasia. He has had many episodes of hematuria,
necessitating readmission to the hospital for multiple blood transfusions and
local cauterization to try to control the bleeding. Earlier in his care, he had
expressed the desire that, should the situation arise when he would be
considered incurable, he did not wish to have his life prolonged by artificial
measures. (He had also expressed these wishes in a living will.) Because of the
aphasia, he is currently unable to communicate with either me or his family, He
continues to have bleeding, and since his family has been unable to handle the
problems at home, I have had to admit him to the hospital many times in the
past few months for both catheter irrigations as well as for blood transfusions.
While I personally think that it is futile to continue to give him blood
transfusions since the underlying tumor remains his son demands that we
continue with active treatment. Would you be willing to see this patient (and
his son)?
Dear
Percy:
I certainly share your, and the family’s
distress. This is, indeed, a very difficult situation. My first effort was
directed to his son. I listened as he explained that even though his father had previously signed
a living will requesting that no undue measures be taken to prolong his life,
there was no way of knowing if, indeed,
his father had since changed his mind.
(Of course, given his father’s current aphasic state, this presumption
is only conjectural). I discussed the very practical considerations involving
the utilization of limited resources, e.g. blood, nursing time, time taken up
by the surgical and nursing staff and the expense of the supplies as well as
the repeated catheter irrigations and bladder cauterizations causing trauma to
his father. His son counter-argued that he has paid into the insurance company
for many years, and his father is entitled to this care. Quite frankly, Percy, I believe that the son
has strong feelings of guilt that he, the son, is not fulfilling his filial
duties if he permits the cessation of active therapy on his father. After a
lengthy with the son, I suggested that his father’s case be presented to the
Ethics Committee of our local hospital, which is made up of medical staff as
well as clergy and lawyers. When all members of the committee agreed that
cessation of active therapy would be the wisest course here, the son accepted
this suggestion with apparent relief, since it seemed to take the burden of
this decision off of him personally.
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EPILOGUE (for MANAGEMENT OF
COMMON UROLOGICAL PROBLEMS)
I feel very privileged to have practiced
medicine for so many years. Gratifying and rewarding are words which describe
my experience. Referrals from other physicians presented me with an opportunity
of sharing my medical philosophy with these physicians. I have found over the
years that informality and humor were appreciated by the medical providers.
I realize that not everyone will agree
with my management of certain medical problems. However, I want to make a plea
that medical providers remain open to the individual needs of their patients as
they guide them in their medical dilemmas--and help them evaluate the numerous
diagnostic and therapeutic options available for most medical problems. We must all try to achieve the optimal
approach for each individual person.
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USING STORYTELLING IN TEACHING
MEDICAL STUDENTS
I believe
that storytelling provides an essential counter-balance to the highly technically
oriented field of modern medicine and helps the medical students develop
healthier and more humane doctor-patient relationships. I have tried to convey
the informational material in a practical, informative, and entertaining
manner, using stories from my own personal experiences to illustrate the points
of discussion. A dual function of
medical educators is to guide medical students through the mass of medical
facts and help them hone their skills of communication with the patient. I have presented some teaching strategies
which are not new, but I feel bear repeating.
BASIC TEACHING STRATEGIES
One basic rule I emphasize to the students: there is no such thing as a dumb question. The students must feel free to question any presented material. They are confronted with a plethora of multiple, often conflicting, ideas and must constantly analyze this information and decide on its relative validity. Maintaining the students’ attention is paramount to the teaching process. Prior to class time, I learn the names of the students via a set of class pictures. If I observe a student with seeming lack of attention, I try to refocus him/her to the discussion at hand. Direct eye to eye contact encourages an active dialogue with the student. For that reason, a totally dark room should be avoided if possible.
FIRST PATIENT ENCOUNTER
During the first such encounter, the medical students often feel more intimidated than the patients. However, the patients have generally been informed of the fact that this is a learning situation for the medical students and are usually desirous of making the student feel comfortable.
ILLUSTRATIVE CASE: During my third year of Medical School, (after two years of having been inundated with lectures and textbooks), we students were informed that that the time had arrived for us to see our first “real” patient in the General Medical Clinic. Needless to say, I was eager, but a bit apprehensive, at the prospect of this new awesome responsibility. I entered the General Medical Clinic. A rather brusque nurse literally shoved me into an examination room. Not knowing what or whom I would encounter greatly increased my anxiety level. But my fears were quickly dissipated by my “patient” ….yes, my very own patient: a delightful 85 year old woman. In a most professional manner (at least, I tried very hard to give the impression of professionalism) I asked what was bothering her. She replied: “Oh Doctor”... (She called me Doctor…I was both excited and delighted!) “My urine has the most terrible odor!” I replied (in the most competent voice that a 3rd year medical student can utter) “I’d like to check a specimen if possible.” She looked up and said: “Of course, Doctor, I’ve brought you a sample.” She then reached into her purse and removed a small vial which she handed to me. I unscrewed the top and took a whiff (trying to do such in a suave fashion…though how does anyone smell urine in a suave fashion?). “My,” said I, “This urine smells sweet.” “Oh yes, Doctor,” said she with a slightly embarrassed smile. “I added a few drops of perfume so the smell of the urine wouldn’t offend you.”
During the first such encounter, the medical students often feel more intimidated than the patients. However, the patients have generally been informed of the fact that this is a learning situation for the medical students and are usually desirous of making the student feel comfortable.
ILLUSTRATIVE CASE: During my third year of Medical School, (after two years of having been inundated with lectures and textbooks), we students were informed that that the time had arrived for us to see our first “real” patient in the General Medical Clinic. Needless to say, I was eager, but a bit apprehensive, at the prospect of this new awesome responsibility. I entered the General Medical Clinic. A rather brusque nurse literally shoved me into an examination room. Not knowing what or whom I would encounter greatly increased my anxiety level. But my fears were quickly dissipated by my “patient” ….yes, my very own patient: a delightful 85 year old woman. In a most professional manner (at least, I tried very hard to give the impression of professionalism) I asked what was bothering her. She replied: “Oh Doctor”... (She called me Doctor…I was both excited and delighted!) “My urine has the most terrible odor!” I replied (in the most competent voice that a 3rd year medical student can utter) “I’d like to check a specimen if possible.” She looked up and said: “Of course, Doctor, I’ve brought you a sample.” She then reached into her purse and removed a small vial which she handed to me. I unscrewed the top and took a whiff (trying to do such in a suave fashion…though how does anyone smell urine in a suave fashion?). “My,” said I, “This urine smells sweet.” “Oh yes, Doctor,” said she with a slightly embarrassed smile. “I added a few drops of perfume so the smell of the urine wouldn’t offend you.”
COMMUNICATING WITH THE PATIENT
I emphasize to the students the importance of establishing a good communication at the start of their relationship with the patient. If successful, this process will give the patient increased confidence in the judgment and ability of their examiner.
COMFORTING THE PATIENT: A 72 year old woman comes to you as a new patient with the complaint of vague abdominal pains. She appears rather frightened, expressing concern that she thinks she has cancer. She uses what might be considered rather “earthy” words to describe her symptoms. How can you best alleviate her anxiety? What steps can you take to make her more comfortable?
Put her at ease and be sensitive to her feelings of insecurity: Since, to her, you are likely the ultimate authority, you must try to establish a comfortable basis for communication. A warm handshake with direct eye to eye contact combined with appropriate introductions is a good start.
Address her appropriately: Do not assume that calling her by her first name, especially on this, her first visit, will create a friendlier relationship. Indeed, this might be insulting to her, particularly since she is likely your senior. Ask her how she would prefer to be addressed. If you choose to address her by her first name, it is only fair to offer her the option of calling you by your first name. Very likely, however, she will opt to address you as “Doctor."
(During patient rounds, I stress that the patient should be addressed by their name, rather than by their disease. I always introduce the patients to the students or residents and make a point of involving the patients in the discussion. I stress that that patients generally feel extremely vulnerable and are very sensitive to any words or actions spoken in their immediate vicinity. I caution the students to avoid any “side remarks” since the patients will inevitably assume that such comments are about them.)
Treat her with respect: Be sensitive to her feelings. Never correct her grammar or give the impression that you feel that she is lacking in education.
I emphasize to the students the importance of establishing a good communication at the start of their relationship with the patient. If successful, this process will give the patient increased confidence in the judgment and ability of their examiner.
COMFORTING THE PATIENT: A 72 year old woman comes to you as a new patient with the complaint of vague abdominal pains. She appears rather frightened, expressing concern that she thinks she has cancer. She uses what might be considered rather “earthy” words to describe her symptoms. How can you best alleviate her anxiety? What steps can you take to make her more comfortable?
Put her at ease and be sensitive to her feelings of insecurity: Since, to her, you are likely the ultimate authority, you must try to establish a comfortable basis for communication. A warm handshake with direct eye to eye contact combined with appropriate introductions is a good start.
Address her appropriately: Do not assume that calling her by her first name, especially on this, her first visit, will create a friendlier relationship. Indeed, this might be insulting to her, particularly since she is likely your senior. Ask her how she would prefer to be addressed. If you choose to address her by her first name, it is only fair to offer her the option of calling you by your first name. Very likely, however, she will opt to address you as “Doctor."
(During patient rounds, I stress that the patient should be addressed by their name, rather than by their disease. I always introduce the patients to the students or residents and make a point of involving the patients in the discussion. I stress that that patients generally feel extremely vulnerable and are very sensitive to any words or actions spoken in their immediate vicinity. I caution the students to avoid any “side remarks” since the patients will inevitably assume that such comments are about them.)
Treat her with respect: Be sensitive to her feelings. Never correct her grammar or give the impression that you feel that she is lacking in education.
Avoid medical jargon: Be
certain that both you and she understand what each of you is saying. Never
assume that she has grasped your explanation. She may give a nod of
comprehension to avoid appearing “uneducated,” yet not know what you said. Try
to use the same words that she used to refer to a particular part of the
anatomy or a symptom. Listen carefully for she may tell you the diagnosis (in
her own words). Drawing pictures or diagrams are often helpful. Good
communication cannot be overemphasized!
Avoid the perception of time constraints: In these days of HMOs there is often pressure to limit the time spent with your patient. However, your patient must never be made to feel that she does not have your full attention. If you converse with her while you are in a sitting position, she will likely perceive that there is no time pressure. (Even if you spent exactly that same amount of time with her when you were in the standing position, she would probably perceive that she was being rushed). During these sessions, you should be interrupted only for emergencies.
Avoid the perception of time constraints: In these days of HMOs there is often pressure to limit the time spent with your patient. However, your patient must never be made to feel that she does not have your full attention. If you converse with her while you are in a sitting position, she will likely perceive that there is no time pressure. (Even if you spent exactly that same amount of time with her when you were in the standing position, she would probably perceive that she was being rushed). During these sessions, you should be interrupted only for emergencies.
Address all of her questions: Before she leaves the office, your last query should be: “Do you have any other questions which you would like to ask me?” (One very distressing, and unsettling, situation for patients is to leave the office, feeling that the doctor did not address all of their concerns.)
INVOLVE THE PATIENT IN
HIS/HER THERAPY:
I like to use the metaphor of a business enterprise as it relates to the patient-physician relationship. The enterprise can be set up with the physician as the boss who gives the orders to the patient. While some patients may favor this approach, it has the potential of putting the patient in an adversarial position. I prefer the concept of “partnership. “ In a joint venture, both you and your patient have a more active incentive to have this enterprise succeed. By understanding the possible diagnostic and therapeutic steps which will be taken, your patient is in a better position to anticipate the course of the disease process. There is definitely a strong therapeutic benefit of self-involvement, not to mention the improved compliance with the therapeutic plan.
I like to use the metaphor of a business enterprise as it relates to the patient-physician relationship. The enterprise can be set up with the physician as the boss who gives the orders to the patient. While some patients may favor this approach, it has the potential of putting the patient in an adversarial position. I prefer the concept of “partnership. “ In a joint venture, both you and your patient have a more active incentive to have this enterprise succeed. By understanding the possible diagnostic and therapeutic steps which will be taken, your patient is in a better position to anticipate the course of the disease process. There is definitely a strong therapeutic benefit of self-involvement, not to mention the improved compliance with the therapeutic plan.
ILLUSTRATIVE CASE: A 58 year old man presents with
symptoms of shortness of breath, exacerbated during pollen seasons. He has been
told by his physician to take anti-histamine medication daily during these
times, but he has experienced marked difficulty with urinating since starting
the medication and has unilaterally decided to discontinue it. He is irritated
by his physician’s dictatorial approach in the prescribing of medications and
feels that he has had no input as to when and how much of the medication he
should take. Unless the physician and the patient are in mutual agreement with
the treatment plan, there is a strong chance that treatment--and results--will
be sub-optimal. You can help this process by involving the patient in his own
treatment decisions. Potential adverse side effects must be discussed with your
patient. (E.g. Antihistamines are notorious for causing problems with voiding,
because of interference with bladder muscle tone.)
Engaging the students is a
primary goal for the educator. Presenting them with stories of personal
experiences usually results in heightened receptiveness to the factual medical material.
